Recent 12-month Period Research Articles

Surgical Outcome Reporting. Moving From a Comic to a Tragic Opera?

To assess the current quality of surgical outcome reporting in the medical literature and to provide recommendations for improvement. In 1996, The Lancet labeled surgery as a "comic opera" mostly referring to the poor quality of outcome reporting in the literature impeding improvement in surgical quality and patient care. We screened 3 first-tier and 2 second-tier surgical journals, as well as 3 leading medical journals for original articles reporting on results of surgical procedures published over a recent 18-month period. The quality of outcome reporting was assessed using a prespecified 12-item checklist. Six hundred twenty-seven articles reporting surgical outcomes were analyzed, including 125 randomized controlled trials. Only 1 (0.2%) article met all 12 criteria of the checklist, whereas 356 articles (57%) fulfilled less than half of the criteria. The poorest reporting was on cumulative morbidity burden, which was missing in 94% of articles (n=591) as well as patient-reported outcomes missing in 83% of publications (n=518). Comparing journal groups for the individual criterion, we found moderate to very strong statistical evidence for better quality of reporting in high versus lower impact journals for 7 of 12 criteria and strong statistical evidence for better reporting of patient-reported outcomes in medical versus surgical journals ( P <0·001). The quality of outcomes reporting in the medical literature remains poor, lacking improvement over the past 20 years on most key end points. The implementation of standardized outcome reporting is urgently needed to minimize biased interpretation of data thereby enabling improved patient care and the elaboration of meaningful guidelines.

PD09-04 INCREASED FREQUENCY OF CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR GENE CARRIER MUTATIONS IN NON-CBAVD INFERTILE MALES

You have accessJournal of UrologyCME1 May 2022PD09-04 INCREASED FREQUENCY OF CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR GENE CARRIER MUTATIONS IN NON-CBAVD INFERTILE MALES Thomas Garcia, J. Sam Fisher, Kenny Kim, and Larry Lipshultz Thomas GarciaThomas Garcia More articles by this author , J. Sam FisherJ. Sam Fisher More articles by this author , Kenny KimKenny Kim More articles by this author , and Larry LipshultzLarry Lipshultz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002535.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Homozygous damaging mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene is the primary cause of congenital bilateral absence of the vas deferens (CBAVD). In addition, a high incidence of heterozygous damaging mutations in CFTR have long been implicated in infertility in non-CBAVD males. In the present study we sought to identify novel carrier mutations significantly associated with male infertility from a panel of 62 genes causing common congenital disorders including cystic fibrosis. METHODS: Over the most recent 18-month period, our center performed expanded carrier screening on 165 men receiving a variety of urological treatments including treatment for male infertility, hypogonadism, erectile dysfunction, hematuria, Peyronie's disease, scrotal mass, varicocele, vasectomy, and vasovasostomy. Of these 165 men, 59 were being treated for infertility with full semen analysis reports confirming abnormal semen parameters in 72% of these men (azoospermia, oligozoospermia, asthenozoospermia, or oligoasthenozoospermia). RESULTS: Of the 62 genes tested in 165 men, heterozygous carrier mutations were detected in 12 genes in 57 men (Table 1). No published association between these gene mutations and male infertility could be found for any of the genes except for CFTR. For CFTR, we found a significant 2.3-fold (P <0.05) increase in the number of infertile men with CFTR mutations (9 out of 59 men, or 15.3% of men) relative to the number of other men (men treated for other conditions) with CFTR mutations (7 out of 106 men, or 6.6% of men). None of the azoospermic men with CFTR mutations had congenital bilateral absence of the vas deferens. CONCLUSIONS: Our results are consistent with, but more robust than those of previous studies due to the increased number of mutations tested for in our study. CFTR function has been shown in the epididymis, CFTR protein is present in developing germ cells and sperm, and its function contributes to events required for capacitation in the female reproductive tract. In conclusion, these data demonstrate that mutations in CFTR, even heterozygous mutations, are a likely cause of non-CBAVD male factor infertility in at least a subset of men affected by CFTR mutations. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e178 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Thomas Garcia More articles by this author J. Sam Fisher More articles by this author Kenny Kim More articles by this author Larry Lipshultz More articles by this author Expand All Advertisement PDF DownloadLoading ...

Equity in Access to Deceased Donor Transplant for Candidates on the Heart Waitlist

<h3>Purpose</h3> Transplantation is often the preferred therapy for individuals with organ failure, but a limited supply of organs prevents all patients from accessing this treatment. The Organ Procurement and Transplantation Network (OTPN) equity in access to transplantation methodology was developed to better understand equity in access to deceased donor (DD) transplant among waitlisted candidates. In 2020, the OPTN launched a publicly accessible dashboard which monitors equity in access to transplantation for lung, liver, and kidney candidates. Most recently, heart was incorporated into the dashboard. <h3>Methods</h3> OPTN data was analyzed using Poisson rate regression modeling to calculate an access to transplant score (ATS) which summarizes a heart candidate's relative likelihood of receiving a DD transplant, controlling for intentional policy-driven differences. The model was built on rolling 6-month cohorts of active heart registrations that waited at least one day between 1/1/2010 and 6/30/2021. The standard deviation (SD) in ATS was presented where smaller SDs reflect a more equitable system. <h3>Results</h3> The overall SD in ATS has remained stable over time. After controlling for medical urgency status, donation service area (DSA), blood type, height and weight were the four factors most associated with inequity in the recent 6-month period. Blood type AB had the highest transplant rates and blood type O the lowest. In addition, taller, less-heavy and younger candidates had better access. <h3>Conclusion</h3> Overall, equity in access to DD heart transplant has remained relatively stable over the past decade despite major policy changes in 2018 (6 tiers) and 2020 (removal of DSA). The equity in access framework provides the heart community with an additional tool for policy development, monitoring and research into equity in access including further investigating disparities associated with DSA which appear to have declined since 2018.

407. Minimum Manufacturing Costs, National Prices and Estimated Global Availability of New Repurposed Therapies for COVID-19

BackgroundCurrently, only dexamethasone, tocilizumab and sarilumab have conclusively been shown to reduce mortality of COVID-19. No drug for prevention or treatment in earlier stages of COVID-19 are yet found, with previously promising drugs such as hydroxychloroquine and remdesivir have been shown to be ineffective. Several new candidates are now being studied in clinical trials. Safe and effective treatments will need to be both affordable and widely available. We therefore revised our original 2020 analysis to reflect recent developments. In this update we analysed the cost of production, current national list prices, and API availability for oral and IV dexamethasone, ivermectin, colchicine, dutasteride, budesonide, baricitinib and monoclonal antibodies tocilizumab and sarilumab.MethodsCosts of production for new and potential COVID-19 drugs (dexamethasone, ivermectin, dutasteride, budesonide, baricitinib, tocilizumab, sarilumab and colchicine) were estimated using an established and published methodology based on costs of active pharmaceutical ingredients (API), extracted from the global shipping records database Panjiva. This was compared with national pricing data from low, medium, and high-income countries. Annual API export volumes from India were used to estimate the current availability of each drug.ResultsRepurposed therapies can be generically manufactured at very low per-course costs: ranging from &2.58 for IV dexamethasone (or &0.19 orally) to &0.12 for ivermectin. No export price data was available for baricitinib, tocilizumab or sarilumab. When compared against international list prices, we found wide variations between countries. Drug API availability was generally good, with colchicine being the most available with sufficient annual API exported for 59.8 million treatment courses. A summary is shown in Table 1.Table 1. Summary of list prices, estimated production costs, and current availability of potential COVID-19 drugs selected for analysis. OD = Once daily, BD = twice per day, EUA = Emergency Use Authorisation (only to be given with remdesivir) *In most recent 12-month period. ConclusionSuccessful management of COVID-19 will require equitable access to treatment for all, not just those able to pay. Repurposed drugs can be manufactured at very low costs if shown to be clinically effective, and offers an affordable, widely available option for patients at all stages of the disease from pre-exposure prophylaxis to asymptotic and mild infections, through to critical care until vaccination coverage is expanded.Disclosures All Authors: No reported disclosures

Comorbidities and co-medications among 28089 people living with HIV: A nationwide cohort study from 2009 to 2019 in Japan.

ObjectivesComorbidities are associated with a high burden of disease in people living with HIV (PLWH). The objective was to investigate the prevalence of chronic comorbidities and use of co‐medications in PLWH in Japan.MethodsThis study retrospectively analysed clinical information from PLWH receiving antiretroviral therapy (ART) between April 2009 and March 2019. Demographic characteristics, numbers and types of chronic comorbidities, and numbers and types of non‐ART co‐medications, were described by age groups. The source of data was the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB).ResultsOverall, 28 089 PLWH (male 91.9%) who used ART were identified. Out of 28 089 PLWH, 81.5% had at least one chronic comorbidity. The numbers of AIDS‐defining cancers and non‐AIDS‐defining cancers in this Japanese cohort were 2432 (8.7%) and 2485 (8.8%), respectively. The cumulative burden of comorbidities including non‐AIDS‐defining cancer increased with age. Changes in trend between 2009 and 2019 were observed, including a higher proportion of PLWH diagnosed at ≥ 70 years old [2019 (4.7%) vs. 2009 (2.4%)] and a decreasing percentage of patients with AIDS‐defining cancers (down from 6.3% to 4.8% between 2009 and 2019). The most common co‐medications during the most recent 3‐month period were lipid‐regulating/anti‐atheroma preparations (11.3%), antacids, antiflatulents and anti‐ulcerants (9.6%), and agents acting on the renin–angiotensin system (8.1%). The three most common therapeutic categories of co‐medications during the study period were antacids, antiflatulents and anti‐ulcerants (35.0%), systemic antihistamines (33.7%) and psycholeptics (27.1%). More than 30% of PLWH aged > 40 years used at least one co‐medication in a 3‐month period, while more than half of PLWH aged > 30 years had at least one co‐medication prescribed concomitantly for a total of ≥ 90 days during the study period, and the numbers of co‐medications used were greater in the older age groups.ConclusionsThe burden of chronic comorbidities and co‐medication were found to be greater in older, as compared to younger patients, among 28 089 PLWH in a nationwide study in Japan. This finding suggests the need to identify elderly PLWH and to appropriately manage their HIV and comorbidities.

Turnaround Time of Plasma Next-Generation Sequencing in Thoracic Oncology Patients: A Quality Improvement Analysis.

Genomic analysis of plasma cell-free DNA has become a widespread tool for advanced non-small-cell lung cancer care. Whereas accuracy has been reported on widely, its usefulness is also tied tightly to its turnaround time (TAT), which is not well studied. We studied the TAT of commercial plasma next-generation sequencing (NGS; Guardant360) for 533 results from 461 patients at our center between August 2016 and October 2019. The study received institutional review board approval as a quality improvement study; therefore, the results of the test and clinical setting were not analyzed. TAT from blood draw to result (median of 9 days) was slightly longer than the TAT from laboratory receipt to result, a median of 7 days. Testing volume at our center increased three-fold over the time of the study. During this period, clinical TAT decreased from an initial median of 12 days to a median of 8 days in 2018, but more recently the median increased slightly to 9 days. During the most recent 12 months, 231 (95%) of 247 cases resulted within 14 days from blood draw, with delayed results usually because of billing, whereas 44 cases (18%) resulted within 7 days of blood draw. Studying 92 cases drawn in the most recent 3-month period, the median time of result receipt was 4:01 pm Eastern Time/1:01 pm Pacific Time; 39 results (43%) were returned after 5:00 pm Eastern Time. In a large single-institution experience, we find that plasma NGS results can routinely be expected within 2 weeks, but uncommonly result within 1 week, supporting the need for new strategies to incorporate plasma NGS into the initial genotyping of advanced non-small-cell lung cancer.

The Architecture of an Internal, Scientific, Presubmission Review Program Designed to Increase the Impact and Success of Grant Proposals and Manuscripts.

Securing extramural grant funding and publishing in peer-reviewed journals are key indicators of success for many investigators in academic settings. As a result, these expectations are also sources of stress for investigators and trainees considering such careers. As competition over grant funding, costs of conducting research, and diffusion of effort across multiple demands increase, the need to submit high-quality applications and publications is paramount. For over 3 decades, the Center for AIDS Prevention Studies at the University of California, San Francisco, has refined an internal, presubmission, peer review program to improve the quality and potential success of products before external submission. In this article, the rationale and practical elements of the system are detailed, and recent satisfaction reports, grant submission outcomes, and plans for ongoing tracking of the success rates of products reviewed are discussed. The program includes both early-stage concept reviews of ideas in their formative state and full product reviews of near-final drafts. Recent evaluation data indicate high levels of reviewee satisfaction with multiple domains of the process, including scheduling the review sessions, preparedness and expertise of the reviewers, and overall quality of the review. Outcome data from reviews conducted over a recent 12-month period demonstrate subsequent funding of 44% of proposals reviewed through the program, a success rate that surpasses the National Institutes of Health funding success rates for the same time period. Suggestions for the sustainability of the program and for its adoption at other institutions and settings less dependent on extramural funding are provided.

A cross-sectional evaluation of five warfarin anticoagulation services in Uganda and South Africa.

Warfarin is the most commonly prescribed oral anticoagulant in sub-Saharan Africa and requires ongoing monitoring. The burden of both infectious diseases and non-communicable diseases is high and medicines used to treat comorbidities may interact with warfarin. We describe service provision, patient characteristics, and anticoagulation control at selected anticoagulation clinics in Uganda and South Africa. We evaluated two outpatient anticoagulation services in Kampala, Uganda and three in Cape Town, South Africa between 1 January and 31 July 2018. We collected information from key staff members about the clinics' service provision and extracted demographic and clinical data from a sample of patients' clinic records. We calculated time in therapeutic range (TTR) over the most recent 3-month period using the Rosendaal interpolation method. We included three tertiary level, one secondary level and one primary level anticoagulation service, seeing between 30 and 800 patients per month. Care was rendered by nurses, medical officers, and specialists. All healthcare facilities had on-site pharmacies; laboratory INR testing was off-site at two. Three clinics used warfarin dose-adjustment protocols; these were not validated for local use. We reviewed 229 patient clinical records. Most common indications for warfarin were venous thrombo-embolism in 112/229 (49%), atrial fibrillation in 74/229 (32%) and valvular heart disease in 30/229 (13%). Patients were generally followed up monthly. HIV prevalence was 20% and 5% at Ugandan and South African clinics respectively. Cardiovascular comorbidity predominated. Furosemide, paracetamol, enalapril, simvastatin, and tramadol were the most common concomitant drugs. Anticoagulation control was poor at all included clinics with median TTR of 41% (interquartile range 14% to 69%). TTR was suboptimal at all included sites, despite frequent patient follow-up. Strategies to improve INR control in sub-Saharan patients taking warfarin are needed. Locally validated warfarin dosing algorithms in Uganda and South Africa may improve INR control.

Exploring the causes of chronic cancer pain and possible remedies.

Exploring the causes of chronic cancer pain and possible remedies.

Superfluous amylase/lipase testing at a tertiary care hospital: a retrospective study.

ABSTRACTBACKGROUND: Measuring both serum amylase and lipase in the setting of acute pancreatitis is not recommended and monitoring changes in amylase and lipase levels after diagnostic results is of little added value. The extent of the two types of superfluous amylase/lipase testing at our institution is unknown.OBJECTIVE: Explore the extent of superfluous amylase/lipase testing.DESIGN: Medical record review.SETTINGS: Tertiary care, teaching hospital.PATIENTS AND METHODS: We retrospectively reviewed all amylase and lipase tests performed over a recent 12-month period. Amylase tests were considered superfluous if they were ordered with lipase tests at the same time or if they were repeated after diagnostic amylase results. They were considered questionably superfluous if they were repeated alone after non-diagnostic amylase results. Lipase tests were considered superfluous if they were repeated after diagnostic lipase results and questionably superfluous if they were repeated after non-diagnostic lipase results.MAIN OUTCOME MEASURES: Number and percentage of lipase and amylase tests that were superfluous or questionably superfluous.SAMPLE SIZE: 23 950.RESULTS: Superfluous testing was identified in 30.6% of 23 950 amylase/lipase tests and questionably superfluous testing in 12.4%. Of the 7330 superfluous tests, 94.8% were due to simultaneous amylase/lipase testing and 5.2% to repeated lipase testing after diagnostic results. The rate of superfluous and questionably superfluous testing was significantly higher in the inpatient setting compared to emergency department or outpatient settings (P<.0001). Of the 6483 amylase tests obtained simultaneously with non-diagnostic lipase tests, only 36 (0.6%) showed a diagnostic result. Furthermore, only 0.7% and 3.6% of amylase tests that were repeated after normal and borderline results, respectively, were diagnostic and 1.1% and 9.3% of lipase tests that were repeated after normal and borderline results, respectively, were diagnostic.CONCLUSIONS: About one third of amylase/lipase testing appears to be superfluous, mainly due to simultaneous amylase/lipase testing. Since only 0.6% of simultaneous amylase/lipase tests showed diagnostic amylase with non-diagnostic lipase levels, quality improvement initiatives should be directed at reducing this low-value practice. Repeating amylase/lipase tests following normal results is of little value.LIMITATIONS: Clinical notes and imaging studies were not reviewed.CONFLICT OF INTEREST: None.

OpenNotes After 7 Years: Patient Experiences With Ongoing Access to Their Clinicians' Outpatient Visit Notes.

BackgroundFollowing a 2010-2011 pilot intervention in which a limited sample of primary care doctors offered their patients secure Web-based portal access to their office visit notes, the participating sites expanded OpenNotes to nearly all clinicians in primary care, medical, and surgical specialty practices.ObjectiveThe aim of this study was to examine the ongoing experiences and perceptions of patients who read ambulatory visit notes written by a broad range of doctors, nurses, and other clinicians.MethodsA total of 3 large US health systems in Boston, Seattle, and rural Pennsylvania conducted a Web-based survey of adult patients who used portal accounts and had at least 1 visit note available in a recent 12-month period. The main outcome measures included patient-reported behaviors and their perceptions concerning benefits versus risks.ResultsAmong 136,815 patients who received invitations, 21.68% (29,656/136,815) responded. Of the 28,782 patient respondents, 62.82% (18,081/28,782) were female, 72.90% (20,982/28,782) were aged 45 years or older, 76.94% (22,146/28,782) were white, and 14.30% (4115/28,782) reported fair or poor health. Among the 22,947 who reported reading 1 or more notes, 3 out of 4 reported reading them for 1 year or longer, half reported reading at least 4 notes, and 37.74% (8588/22,753) shared a note with someone else. Patients rated note reading as very important for helping take care of their health (16,354/22,520, 72.62%), feeling in control of their care (15,726/22,515, 69.85%), and remembering the plan of care (14,821/22,516, 65.82%). Few were very confused (737/22,304, 3.3%) or more worried (1078/22,303, 4.83%) after reading notes. About a third reported being encouraged by their clinicians to read notes and a third told their clinicians they had read them. Less educated, nonwhite, older, and Hispanic patients, and individuals who usually did not speak English at home, were those most likely to report major benefits from note reading. Nearly all respondents (22,593/22,947, 98.46%) thought Web-based access to visit notes a good idea, and 62.38% (13,427/21,525) rated this practice as very important for choosing a future provider.ConclusionsIn this first large-scale survey of patient experiences with a broad range of clinicians working in practices in which shared notes are well established, patients find note reading very important for their health management and share their notes frequently with others. Patients are rarely troubled by what they read, and those traditionally underserved in the United States report particular benefit. However, fewer than half of clinicians and patients actively address their shared notes during visits. As the practice continues to spread rapidly in the United States and internationally, our findings indicate that OpenNotes brings benefits to patients that largely outweigh the risks.

Injecting drug use: Gendered risk

BackgroundResearch demonstrates gender related differences in drug-use practices and risk behaviours. Females’ structural vulnerability stemming from traditional gender roles and gender-power relations may enhance their propensity to experience injecting related risk. In this paper we explore gender differences in injection practices at the initiation event, during the first year of injecting and in the most recent 12-month period, to inform more effective harm reduction strategies. MethodsData used in this study were drawn from the Global Drug Survey 2015. The study employs chi-square and logistic regression to assess gender differences in injection behaviours in a sample of current injectors residing in six global regions: North-West Europe; Southern Eastern Europe; North America. South America and Oceania. ResultsFemales were more likely than males to report being injected by an intimate partner at initiation (OR = 4.4, 95%CI: 2.2–8.8), during the first year of injecting (OR = 4.8, 95% CI: 2.4–9.3) and in the most recent 12-month period (OR = 2.5, 95%CI: 1.0–6.2). Females reported greater difficulties accessing sterile equipment (X2(2,N = 453) = 8.2, p = 0.02) and were more likely to share injecting equipment than males (X2(1,N = 463) = 3.9, p = 0.05). ConclusionsOur findings highlight females’ continued dependence on their intimate partner to administer the injection into the first year of their injecting career. Females remained more likely than males to rely on intimate partners for injection during the most recent 12-month period. Females report greater difficulties in sourcing sterile equipment and are more likely to share injecting equipment. We suggest that these findings reflect the broader social structure in which females are disempowered through traditional gender roles and the lack of gender appropriate harm reduction services.

Tube feeding monitoring as a clinical quality indicator at intensive care units

Malnutrition is particularly prevalent among intensive care unit (ICU) patients, being associated with poor clinical results. Enteral nutrition (EN) offers multiple benefits on critically ill patients and its monitoring was established by the Spanish Society of Critical Care (SEMICYUC) as a clinical quality indicator (CQI; EN patients correctly monitorized / all EN patients, as %). However, no results have been published on its regulated monitoring. Assessing CQI's compliance, identifying difficulties and possibilities for its use. In a recent 18-month period, the CQI was assessed in ICU patients following SEMYCIUC criteria. This CQI, although offered as a unique indicator, has different components, giving rise to multiple results. The settled standard (100%) was only reached by some of these components, i.e.: feeding tube position control plus verification of vomiting, regurgitation and aspiration. We propose to elaborate a daily checklist, including the different components that integrate this CQI, for its joint completion by nurses and physicians for all patients receiving EN.

Discussing and prescribing expensive unfunded anticancer drugs in Australia

ObjectiveAustralia has a publicly funded universal healthcare system which heavily subsidises the cost of most registered anticancer drugs. The use of anticancer drugs that are unfunded, that is, not subsidised by the government, entails substantial out-of-pocket costs for patients. We sought to determine how frequently Australian medical oncologists discuss and prescribe unfunded anticancer drugs, and their attitudes and beliefs about their use.MethodsMembers of the Medical Oncology Group of Australia (MOGA) completed an online survey about their clinical practices over a recent 3-month period. A negative binomial regression model was used to examine the influence of respondent characteristics on the rate of discussions about, and prescription of, unfunded anticancer drugs.ResultsOf the 154 respondents (27% of 575 MOGA members), 92% had discussed and 68% had prescribed at least one unfunded anticancer drug in the last 3 months. Respondents reported discussing unfunded anticancer drugs with an average of 2.5 patients per month (95% CI 2.1 to 2.9), and prescribed them to an average of 0.9 patients per month (95% CI 0.7 to 1.2). The rate of discussing unfunded anticancer drugs was associated with being fully qualified (p=0.01), and being in a metropolitan practice (p=0.009), the rate of prescription was associated only with being in metropolitan practice (p=0.006). The concerns about discussing and prescribing unfunded anticancer drugs rated most important were as follows: ‘potential to cause financial hardship’ and ‘difficulty for patients to evaluate the benefits versus the costs’.ConclusionsAustralian medical oncologists frequently discuss and prescribe unfunded anticancer drugs, and are concerned about their patients having to face difficult decisions and financial hardship. Further research is needed to better understand the factors that affect how oncologists and patients value expensive, unfunded anticancer drugs.

The bull's eye sign and other suprainguinal venographic findings to limit the use of intravascular ultrasound in patients with severe venous stasis.

When assessing the common femoral and suprainguinal veins in patients with venous stasis, it is generally agreed that use of intravascular ultrasound (IVUS) is mandatory. This widely held dogma is reinforced by the fact that extrinsic compression of the iliac veins does not reproduce images consistent with eccentric stenosis as one sees in the arterial system. In an attempt to identify a subgroup of patients where the use of IVUS could be averted, we analyzed and carefully evaluated the images of patients who had both standard contrast venograms and IVUS examinations. Ninety-two common femoral and suprainguinal venograms performed during a recent 6-month period were randomly selected for analysis. Good quality venographic images were found in 88 of these limbs (78 patients) that also had IVUS data formed the basis of this analysis. All venograms included visualization of the common femoral, external and common iliac veins, and inferior vena cava. These veins were classified as (1) normal to mild (type I) vein narrowing or dilatation of ≤20% compared with the adjacent segment, (2) moderate (type II) ≥21%-40%, (3) severe (type III) ≥41%, and (4) bull's eye sign (type IV). The latter was defined as a central circle with minimal or no dye within a dilated vein and forking of the dye around the circle. In the present series, no 1-month mortality or 1-month morbidity was observed in these patients. The Clinical, Etiologic, Anatomic, and Pathologic (CEAP) classification score was class II in 24 cases (26%), class III in 36 cases (39%), class IV in 17 cases (18%), class V in nine cases (10%), and class VI in six cases (7%). There was no venographic or IVUS evidence of inferior vena cava stenosis or dilatation in this series. Of the venograms studied, 88 had positive intravascular ultrasound (PIVUS) or positive predictive value findings. The correlation of venographic findings and PIVUS was as follows: type I cases (26) had 85% PIVUS; type II (22) had 100% PIVUS; type III (25) had 100% PIVUS, and type IV (19) had 100% PIVUS. The new proposed classification of venographic findings can be used to treat more than two-thirds of the patients without resorting to the use of IVUS.

Management of patients with acute aortic syndrome through a regional rapid transport system

ObjectiveThe objective of this study was to describe the outcomes of patients with acute aortic syndrome (AAS) during and after transfer to a regional aortic center by a rapid transport system. MethodsReview of patients with AAS who were transferred by a rapid transport system to a regional aortic center was performed. Data regarding demographics, diagnosis, comorbidities, transportation, and hospital course were acquired. Severity of existing comorbidities was determined by the Society for Vascular Surgery Comorbidity Severity Score (SVSCSS). The Acute Physiology and Chronic Health Evaluation II (APACHE II) score assessed physiologic instability on admission. Risk factors associated with system-related (transfer and hospital) mortality were identified by univariate and multivariate linear regression analysis. ResultsDuring a recent 18-month period (December 2013-July 2015), 183 patients were transferred by a rapid transport system; 148 (81%) patients were transported by ground and 35 (19%) by air. Median distance traveled was 24 miles (range, 3.6-316 miles); median transport time was 42 minutes (range, 10-144 minutes). Two patients died during transport, one with a type A dissection, the other of a ruptured abdominal aortic aneurysm. There were 118 (66%) patients who received operative intervention. Median time to operation was 6 hours. Type B dissections had the longest median time to operation, 45 hours, with system-related mortality of 1.9%; type A dissections had the shortest median time, 3 hours, and a system-related mortality of 16%. Overall, system-related mortality was 15%. On univariate analysis, factors associated with system-related mortality were age ≥65 years (P = .026), coronary artery disease (P = .030), prior myocardial infarction (P = .049), prior coronary revascularization (P = .002), SVSCSS of >8 (P < .001), abdominal pain (P = .002), systolic blood pressure <90 mm Hg at sending hospital (P = .001), diagnosis of aortic aneurysm (P = .013), systolic blood pressure <90 mm Hg in the intensive care unit (P < .001), and APACHE II score >10 (P = .004). Distance traveled and transport mode and duration were not associated with increased risk of system-related mortality. Only SVSCSS of >8 (odds ratio, 7.73; 95% confidence interval, 2.32-25.8; P = .001) was independently associated with an increase in system-related mortality on multivariate analysis. ConclusionsImplementation of a rapid transport system, regardless of mode or distance, can facilitate effective transfer of patients with AAS to a regional aortic center. An SVSCSS of >8 predicted an increased system-related mortality and may be a useful metric to assess the appropriateness of patient transfer.

Blood glucose self-monitoring and internet diabetes management on A1C outcomes in patients with type 2 diabetes

ObjectivesThe purpose of this study was to determine any correlation between frequency of self-monitoring of blood glucose (SMBG), frequency of patient-provider communication of SMBG (reporting), and hemoglobin A1C for patients...

Enriched Audience Engagement Through Twitter: Should More Academic Radiology Departments Seize the Opportunity?

PurposeThe aim of this study was to evaluate use of the microblogging social network Twitter by academic radiology departments (ARDs) in the United States. MethodsTwitter was searched to identify all accounts corresponding with United States ARDs. All original tweets from identified accounts over a recent 3-month period (August to October 2014) were archived. Measures of account activity, as well as tweet and link content, were summarized. ResultsFifteen ARDs (8.2%) had Twitter accounts. Ten (5.5%) had “active” accounts, with ≥1 tweet over the 3-month period. Active accounts averaged 711 ± 925 followers (maximum, 2,885) and 61 ± 93 tweets (maximum, 260) during the period. Among 612 tweets from active accounts, content most commonly related to radiology-related education (138), dissemination of departmental research (102), general departmental or hospital promotional material (62), departmental awards or accomplishments (60), upcoming departmental lectures (59), other hospital-related news (55), medical advice or information for patients (38), local community events or news (29), social media and medicine (27), and new departmental or hospital hires or expansion (19). Eighty percent of tweets (490 of 612) included 315 unique external links. Most frequent categories of link sources were picture-, video-, and music-sharing websites (89); the ARD’s website or blog (83); peer-reviewed journal articles (40); the hospital’s or university’s website (34), the lay press (28), and Facebook (14). ConclusionsTwitter provides ARDs the opportunity to engage their own staff members, the radiology community, the department's hospital, and patients, through a broad array of content. ARDs frequently used Twitter for promotional and educational purposes. Because only a small fraction of ARDs actively use Twitter, more departments are encouraged to take advantage of this emerging communication tool.

Chronic Manual Exchange Transfusions Compared with Erythrocytapheresis in Children and Teens with Sickle Cell Disease

Background:Children and young adults with sickle cell disease (SCD) are at high risk of strokes and are frequently treated with red blood cell (RBC) transfusions. RBCs may be given by simple transfusion, manual exchange transfusion (ME), or erythrocytapheresis (ECP) with a goal of suppressing hemoglobin (Hb) S while minimizing transfusion-induced iron overload. There have been no formal comparisons of these modalities, and practices for transfusion management vary among institutions. We compared transfusion therapy outcomes among patients with SCD undergoing transfusion therapy for primary or secondary stroke prevention, hypothesizing that children would be more likely to achieve Hb S suppression and ferritin goals while receiving ECP. We also compared complications of transfusion therapy across transfusion modalities.Methods:This is a single-institution retrospective cohort study of 38 patients with SCD who received chronic transfusion therapy for primary or secondary stroke prevention from 1/1/2008 through 12/31/2012. Per institutional practice, younger patients receive ME for stroke prevention; they are offered ECP when their size is adequate for a large-bore double-lumen implantable port, but may choose to continue ME. The pre-transfusion Hb S goal is <30% for at least 2 years, then may be liberalized to <50% for subjects without either abnormal transcranial Doppler ultrasound or infarct recurrence. Hb S percentage and ferritin were measured prior to each transfusion. Patients on transfusion therapy for 6 or more months were included; one child who had a stroke after brain tumor biopsy was excluded. Subjects were censored at last date of follow-up or date of hematopoietic stem cell transplant. The following factors were evaluated: duration and mode of transfusion therapy, achievement of Hb S suppression goal, ferritin levels, and catheter complications. Categorical variables were compared with Fisher’s exact test and medians with the Mann-Whitney U-test in SPSS version 21 (IBM, Armonk, NY).Results:During the study period, 38 subjects (42% male) met all inclusion criteria. Of these, 5 received exclusively ECP, 17 received exclusively ME, and 16 received both modalities during the study period. For the most recent 12-month period of data for each participant, 13 received ECP and 25 received ME. There was no association between modality of transfusion and the proportion of visits during which subjects achieved their pre-transfusion Hb S goal during the 12-month period. The median proportion of visits achieving the Hb S goal was 0.80 for ECP (IQR 0.40-1.0) versus 0.50 for ME (IQR 0.28-0.90) (p=0.27). Furthermore, there was no significant difference in ferritin concentrations between transfusion modalities: median 875 ng/ml for ECP (IQR 578-2659) versus median 1527 ng/ml for ME (IQR 731-2568) (p=0.56).Children who had ever received ECP had a significantly longer total duration of transfusion therapy (median 97 months, IQR 51.5-134) than those receiving ME only (median 28 months, IQR 12.5-47) (p<0.001). Among 21 subjects who had ever received ECP, 15 (71.4%) experienced one or more catheter complications, including infection, thrombosis, catheter leakage, or venous stenosis, compared with 1/17 subjects (5.8%) who had never received ECP (OR for catheter complications 40 for subjects who had ever received ECP, 95% CI 4.29, 372.4, p <0.001). Five subjects switched from ECP to ME due to stenosis of the great vessels that precluded double-lumen port replacement.Conclusions:Children with SCD receiving ECP and ME for stroke prevention in this cohort had similar achievement of Hb S suppression goals and iron overload management. Additional patient-specific factors may be responsible for variations in pre-transfusion Hb S and ferritin concentrations. Catheter complications were significantly more common in children and adolescents receiving ECP compared with ME, likely due to the large-bore double-lumen port utilized for ECP at our center. DisclosuresNo relevant conflicts of interest to declare.

Reducing costs while maintaining quality in endovascular neurosurgical procedures.

As medical costs continue to rise during a time of increasing medical resource utilization, both hospitals and physicians must attempt to limit superfluous health care expenses. Neurointerventional treatment has been shown to be costly, but it is often the best treatment available for certain neuropathologies. The authors studied the effects of 3 policy changes designed to limit the costs of performing neurointerventional procedures at the University of Michigan. The authors retrospectively analyzed the costs of performing neurointerventional procedures during the 6-month periods before and after the implementation of 3 cost-saving policies: 1) the use of an alternative, more economical contrast agent, 2) standardization of coil prices through negotiation with industry representatives to receive economies of scale, and 3) institution of a feedback method to show practitioners the costs of unused products per patient procedure. The costs during the 6-month time intervals before and after implementation were also compared with costs during the most recent 6-month time period. The policy requiring use of a more economical contrast agent led to a decrease in the cost of contrast usage of $42.79 per procedure for the first 6 months after implementation, and $137.09 per procedure for the most current 6-month period, resulting in an estimated total savings of $62,924.31 for the most recent 6-month period. The standardized coil pricing system led to savings of $159.21 per coil after the policy change, and $188.07 per coil in the most recent 6-month period. This yielded total estimated savings of $76,732.56 during the most recent 6-month period. The feedback system for unused items decreased the cost of wasted products by approximately $44.36 per procedure in the 6 months directly after the policy change and by $48.20 per procedure in the most recent 6-month period, leading to total estimated savings of $22,123.80 during the most recent 6-month period. According to extrapolation over a 1-year period, the 3 policy changes decreased costs by an estimated $323,561.34. Simple cost-saving policies can lead to substantial reductions in costs of neurointerventional procedures while maintaining high levels of quality and growth of services.